Expertise in Transnational Healthcare Delivery: Professional versus Amateur Aid
International nongovernmental organizations (INGOs) are key organizational actors in transnational healthcare service delivery, but the kinds of personnel who lead, work, and volunteer within these organizations is heterogeneous and constantly shifting. The rationalization of the nonprofit sector in the twentieth century resulted in INGOs hiring professionals with management- and development-related credentials (e.g., MPAs, PhDs). In recent decades, however, ordinary lay citizens without such credentials are increasingly establishing their own INGOs to deliver healthcare services abroad. The types of health services and the roles of volunteers vary greatly between “professional” and “amateur” INGOs, with each producing its own organizational interaction order that creates distinctive forms of knowledge about health and development. The central questions that guide my research, then, are: (1) What kinds of expertise do INGO leaders, staff, and volunteers define as relevant to their work in professional and amateur organizations?; (2) What organizational and institutional conditions enable professionals and amateurs to utilize their expertise when delivering healthcare services transnationally?; and, more practically, (3) What implications do different articulations of expertise have for communities being served?
My dissertation research project, supported by multiple prestigious external fellowships including a Fulbright award and Boren fellowship (declined), explores these questions through a comparative ethnography of three “amateur” INGOs in Cambodia that each provide different kinds of healthcare services (e.g., surgical care, primary care, health screenings) but all rely on foreign volunteer healthcare professionals to treat patients. Drawing upon 950 hours of ethnographic observations and 150 interviews with INGO leaders, local staff, and foreign volunteers across the three INGO cases, I seek to answer, “How do transnational healthcare professionals, and the organizations in which they work, manage the application of medical expertise in new settings?”
In my first substantive chapter, I focus on a single INGO case in which foreign volunteers and local staff struggle to interpret each other’s credentials to establish divisions of labor based on expertise. I find that such “credential-based ambiguity,” as I call it, is primarily due to differences in how medical schools are accredited across countries and forces foreign volunteers and local staff to develop their own sense-making strategies to understand each other’s expertise. I further find, however, that foreign volunteers’ status as healthcare professionals from the Global North gives them outsized influence in negotiations about expertise and expert status. I thus apply Relational Inequality Theory to show that foreign volunteers make claims about their believed superior medical expertise to exploit local staff and exclude them from opportunities to engage with patients and build their medical expertise. Such a finding is ironic since this particular INGO has the explicit mission of building the technical capacity of its local staff. My findings thus help explain why medical experts and expertise continue to be disproportionately concentrated in the Global North despite efforts from INGOs and other organizations to build health system capacity and professionals’ technical capacity in the Global South.
My second substantive chapter introduces a second INGO case for a comparative analysis that seeks to explain why foreign volunteers at one INGO, but not the other, are able to effectively import and adapt their medical expertise when collaborating with local staff to treat patients. By adopting the relational approach to expertise, I show that these differences are not due to the content of medical expertise (i.e., the objective knowledge and skills that constitute biomedicine) but rather different configurations of actors, institutions, technologies, and concepts that enable and confer legitimacy to utilizations of medical expertise. Since claims to expertise are a source of professional power, my findings illuminate the organizational and institutional conditions that variously support or undermine professionals’ authority in foreign settings.
My final substantive chapter draws upon 21 interviews that I conducted prior to beginning dissertation fieldwork in Cambodia with amateur INGO leaders who deliver healthcare services to developing countries throughout the world. I seek to understand how these leaders form partnerships with various organizations in the United States, like universities, hospitals, and firms, to acquire needed resources. Breaking from dominant perspectives on nonprofit collaboration, like resource dependence theory and transaction costs, I argue that amateur INGOs’ partnerships with other domestic organizations follow garbage can dynamics. That is, whether partnerships develop and the form they take are largely contingent on the alignment of random, unpredictable streams of problems, solutions, participants, and decision opportunities. The findings help explain how amateur INGO leaders, who are disconnected from the institutionalized aid industry, are able to fulfill their health-promoting missions in developing countries despite lacking access to professional organizations, resources, and expertise.
Collectively, these chapters make multiple contributions to literatures on organizations, professionals, expertise, and global health. They demonstrate the various constraints that professionals from diverse countries face when working together to deliver health care in foreign settings, illuminate processes that generate inequalities among professionals and between patients in the Global North and Global South, and provide practical insights that can be readily incorporated into organizational and professional practices to improve service delivery.